The effects of temperament type on infusion extravasation in newborns

Infusion extravasation has an increased incidence in newborns, which can result in various adverse outcomes. This study aimed to investigate the effects of different types of temperament on infusion extravasation in newborns. A total of 209 newborns aged 4–7 days who were treated with infusion therapy were assessed for temperament type using the neonatal behavioral assessment scale score (NBAS). The 2009 Infusion Nurses Society clinical grading criteria for extravasation were used, and the clinical data of the newborns, such as gestational age and body weight, were collected. Out of 209 newborns assessed, 107 developed infusion extravasations, with an incidence rate of 51.2%. Newborns with intermediate temperament type were more prone to develop infusion extravasation. Newborns with low body weight, amniotic fluid aspiration syndrome, or meconium aspiration syndrome were prone to develop infusion extravasation. Body weight, temperament type of consolability, temperament type of peak of excitement, diseases, general temperament type, and NBAS total scores of the neonates were independent risk factors for infusion extravasation. Thus, different types of temperament can have an impact on neonatal extravasation.


Study measurement
Neonatal behavioral neurological assessment We used the neonatal behavioral assessment scale (NBAS) to assess the temperament types of the newborns, and the Chinese version scale sensitivity is 88.9% and specificity is 82.5% 17,25 .The different temperament types of the newborns were preliminarily assessed based on the scores of six behavioral items related to the neonatal temperament classification, including consolability with intervention, peak of excitement, rapidity of buildup, irritability, lability of states, and self-quieting activity.For consolability with intervention item scores, 1-3 points meant high level, 4-6 points meant medium level, and 7-9 points meant low level; except for that, all other items scores are divided into low level for 1-3 points, medium level for 4-6 points, and high levels for 7-9 points based on the average score of the 9-point scale 26,27 .The different temperament types were then divided into three groups according to scores from 1 to 9 of each behavioral item: excitatory, intermediate, and mild.The three temperament types, namely mild, intermediate, and excitatory, were determined according to the total scores from 1 to 54 of the assessment, with 6-18 points classified as mild, 19-36 points as intermediate type, and 37-54 points as excitatory type 26,27 .
Newborns aged 4-7 days were assessed by a trained and qualified examinator at the interval between feedings and the beginning of sleep in a quiet, semi-dark environment at a room temperature of 24-28 ℃.The assessment items and the duration of each assessment were recorded, and all assessments were completed within 10 min 27 .

Clinical grading criteria for extravasation
In this study, the 2009 Infusion Nurses Society clinical grading criteria for extravasation were used to evaluate the degree of infusion extravasation in newborns.The grading of infusion extravasation was as follows: grade 0, no relevant symptoms; grade 1, blanched skin and edema with a maximum diameter less than 2.5 cm, with or without pain; grade 2, blanched skin and edema with a maximum diameter from 2.5 to 15 cm, cool to touch, with or without pain; grade 3, blanched skin, translucent, edema with a maximum diameter over 15 cm, cool to touch, mild to moderate pain, possible numbness; grade 4, blanched skin, translucent, tight skin, leaking, discolored skin, bruised, swollen, edema with a minimum diameter over 15 cm, deep pitting tissue edema, circulatory impairment, moderate to severe pain, blood product, irritant, or vesicant infiltration 28 .
Once infusion extravasation was detected, the evaluator immediately measured the maximum diameter of the extravasation site of the newborn using a ruler, measured the skin temperature with a clinical thermometer, and judged the severity of neonatal infusion extravasation according to the grading criteria.
Clinical data, such as gestational age, body weight, and diseases of all newborns, were collected from the hospital information system.

Ethical approval
Written informed consents were obtained from all newborn patients' parents or their family members.The study and verbal informed consents were approved by the Institutional Ethical Committee of Nanning Maternity and Child Health Hospital.All study methods were carried out in accordance with relevant guidelines and regulations according to the Declaration of Helsinki.

Occurrence and clinical feature on neonatal infusion extravasation incidence
In this study, a total of 107 newborns developed infusion extravasation, accounting for 51.2%, indicating a relatively high incidence of extravasation in newborns.Among the 107 newborns with infusion extravasation, newborns with low body weights were more prone to infusion extravasation (t = − 5.83, P < 0.05) (Table 1).In addition, the incidence of infusion extravasation was higher with amniotic fluid aspiration syndrome and meconium aspiration syndrome (x 2 = 33.48,P < 0.05) (Table 2).

Role of neonatal behaviors and temperament types on infusion extravasation
In this study, good consolability and the total score of temperament assessment were significantly correlated with the incidence of infusion extravasation in newborns (t value were 12.85 and 7.15, respectively; all P < 0.05) (Table 3).Among the newborns with infusion extravasation, the dominant temperament type was the intermediate type (x 2 = 13.68,P < 0.05).The primary behaviors that influenced infusion extravasation were consolability and peak of excitement (x 2 value were 96.95 and 38.43, respectively; both P < 0.05) (Table 4).

Discussion
For newborns, infusion extravasation is not only accompanied by pain but also increases the risk of infection due to impaired skin integrity and can cause disability and death due to its escalation 3,5 .Furthermore, the adverse consequences caused by infusion extravasation often require more therapeutic drugs and care, increasing treatment costs and social and economic burdens 29 .Some neonatal diseases such as amniotic fluid aspiration and meconium aspiration, would affect vascular or subcutaneous lesions, and then resulting in infusion extravasation 30,31 .In this study, we have found out that amniotic fluid aspiration syndrome and meconium aspiration syndrome would have an impact on infusion extravasation in newborns.Inhalation of amniotic fluid during delivery by a fetus result in its rapid absorption by the alveolar capillaries.The sebum and exfoliated keratinized epithelial cells in the amniotic fluid can result in chemical and mechanical stimulation of the alveoli, increasing the permeability of the pulmonary blood vessels and decreasing gas diffusion, causing alveolar edema and even collapse.Meanwhile, due to the decrease in pH value and PaO 2 and the increase in PaCO 2 , the newborn is in a hypercoagulable state, which leads to hypoxemia, hypercapnia, and severe vasoconstriction, increasing the difficulty in placing the peripheral indwelling needle and the incidence of infusion extravasation 30,31 .Moreover, when neonatal meconium aspiration syndrome occurs, the amniotic fluid contaminated by feces is inhaled by the fetus into the respiratory tract, causing mechanical obstruction and chemical inflammation of the alveoli and respiratory tract.Since the meconium-contaminated amniotic fluid contains many substances, such as bile acid, large particles of meconium, and bilirubin, their mixture results in high viscosity that can easily block the small trachea and bronchi of the newborns, causing neonatal hypercapnia and hypoxemia, leading to vasoconstriction, which further causes increased peripheral vascular resistance, increasing the difficulty of venipuncture and inducing infusion extravasation 32,33 .
Temperament refers to individual differences that are biologically based.It is a component of personality, which may change over time, and reflects behavioral tendencies; besides, temperament is inborn, from birth, each newborn responds to external stimulations in a unique way, and each newborn has a unique style 34 .Studies have shown that newborn temperament types are mainly classified into excitatory, mild, and intermediate types, and newborns with different temperament types have different performances 35 .
Temperament, a stable psychological trait to measure individual differences in behavior, can influence and predict individual behaviors to a certain extent.Moreover, children with different temperament types exhibit different behaviors when exposed to the same external stimulation 36 .A previous study that used NBAS to evaluate newborns found that a low level of self-regulation in newborns and infants was correlated with a low level of self-regulation and changes in sleep rhythm 37 .In addition to external factors, neonatal extravasation is also affected by newborn factors, such as vascular elasticity, puncture site, and disease state 37 .This study has found that neonatal extravasation is also affected by temperament type, and newborns with different temperament types had different incidences of infusion extravasation.
Newborns have a low tolerance for pain caused by venipuncture, and are prone to crying and struggling and are discomfort during venipuncture 38 .Excitatory newborns are active during infusion therapy, making it difficult to accurately place the needle and catheter.However, the crying, restlessness, and irritability of newborns results in increased focus from nurses, leading to a reduced occurrence of infusion extravasation.The mild newborns,  www.nature.com/scientificreports/unlike the ones with excitatory and intermediate temperament types, are quiet, inactive, and more cooperative with the puncture procedure.Even if there is pain caused by infusion extravasation, they rarely show it through crying, restlessness, or other ways, it can only be detected by the nursing rounds in infusion extravasation.For newborns with intermediate temperament type, venipuncture is a very unpleasant stimulation, and they may show irritability and cry but are easy to comfort compared to excitatory newborns.However, they are relatively active during most of their waking hours, and thus they are most likely to experience infusion patch loosening and falling off and indwelling cannula slipping out of the vessel during infusion therapy, with the highest incidence of infusion extravasation 39 .Among limitations in this study have the following.First, this study was a single-center study.In addition, this study was a cross-sectional open study, and no blinding was used.
In conclusion, the different temperament types of newborns showed to affect neonatal extravasation, suggesting that nurses and healthcare professionals in the neonatal unit should pay attention to newborn temperament too, when conducting intravenous infusion therapy, nursing rounds, and management to prevent the occurrence of infusion extravasation.
Statistical analysis was conducted using IBM SPSS Statistics version 26.0.Continuous variables were expressed as mean ± standard deviation (x ± s).Categorical variables were represented as frequencies and percentages.Student's t-test was used to analyze the comparison of continuous variables.Comparison of categorical variables was performed using the chi-square test or χ 2 test.Multivariable logistic regression analysis was employed to https://doi.org/10.1038/s41598-024-66218-3www.nature.com/scientificreports/identify independent factors influencing extravasation of intravenous fluids in newborns.Statistical significance was set at P < 0.05.

Table 1 .
Clinical feature and neonatal infusion extravasation.

Table 5 .
Logistic regression analysis for neonatal infusion extravasation.